Medical ethics during the COVID-19 pandemic

Dr. Dave On Call

In Episode 5 of Dr. Dave On Call, we discuss medical ethics during the COVID-19 pandemic with Dr. Lisa Anderson-Shaw. She is the Former Director of the Clinical Ethics Consult Service, Assistant Clinical Professor at The University of Illinois Medical Center in Chicago, Illinois.

The COVID-19 pandemic has caused us to scrutinize our healthcare capacity, as we all try to do our own part to "flatten the curve". Some key questions arise: 1) What happens if I get COVID-19 and go to a hospital with limited healthcare resources? 2) What happens if there are a limited number of mechanical ventilators? 3) What protocols are in place during the COVID-19 pandemic to help guide these decisions?

During the COVID-19 pandemic, hospitals will utilize the concepts of "Beneficence", an ethical principle that all actions are intended to benefit the patients. Beneficence of a patient must be balanced with the group of individuals who are affected. Further, "Distributive Justice" according to the Principles of Biomedical Ethics, refers to fair, equitable and appropriate distribution determined by justified norms that structure the terms of social cooperation. These 2 principles can help provide a foundation for a clinical decision model that providers will use during pandemics.

A clinical model for decision making was created by Dr. Anderson-Shaw with Dr. Lin at The University of Illinois Medical Center in Chicago in response to the 2009 H1N1 influenza pandemic. This clinical model for decision making serves as a foundation for many hospital systems in our country today and will be an example model for the COVID-19 pandemic:

This clinical decision model includes:

1) Formation of a Pandemic Triage Committee: This Committee would be a neutral and impartial entity serving as the supervising body when a medical center faces resource allocation decisions.

2) Phased allocation of resources: Maximize the utility of resources as dictated by the nature and severity of the situation.

3) Clinical evaluation: The pandemic triage protocol, defined based on levels of severity (3 levels in total) if resources are not exhausted, at capacity or over capacity.

4) Checklist of clinical progress: Using objective findings like SOFA scores and critical care color coded triage tools.

5) Palliative care protocol: For those who do not initially qualify for critical care and those who may not qualify for any reason.

6) Appeals process: The patient or decision maker has the ability to speak with the Attending Physician if there is a question/concern regarding the treatment plan. Also, a patients or decision maker could appeal to the Pandemic Triage Committee regarding decisions about who should or should not receive mechanical ventilators.

7) Early family involvement: Families of patients must be aware of the protocol and engaged into the clinical decision model from the beginning.

If we reach our healthcare capacity during the COVID-19 pandemic and there is a shortage of mechanical ventilators, there will be a clinical decision model implemented by hospitals. This allows patients and their families clarity on how the resources are allocated during the COVID-19 pandemic.

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Citations:

Lin J., Anderson-Shaw L. Rationing of resources: Ethical issues in Disasters and Epidemic Situations. https://doi.org/10.1017/S1049023X0000683X